Examination of Witnesses (Questions 1320-1339)
11 MARCH 2004
MS MELANIE
JOHNSON MP, MS
IMOGEN SHARP,
MS DANILA
ARMSTRONG AND
DR ADRIENNE
CULLUM
Q1320 Chairman: I think what both David
Amess and Paul Burstow were trying to get out of you is on the
scale of carrot here, stick there, where are we? I am not entirely
clear from your answers exactly where you are at because you are
implying more or less that this will all be resolved in the White
Paper. We are getting messages, certainly from Tessa Jowell who
is ruling out certain steps on advertising bans that are being
introduced in other European countries, so in advance of that
we get the impression that there is more carrot than stick and
I think we need to be aware of what your thoughts are in framing
our own recommendations in this inquiry.
Miss Johnson: I think that balance
is something that may be different for different issues, but I
am sure you have actually read what Tessa Jowell said and, as
you know, the reporting of it in the headlines is not really accurate.
Tessa said much more: the voluntary route was one route; there
was still the question about the bans. As I said earlier on, the
Food Standards Agency board is only today coming forward with
its recommendations as a result of the work that it has been doing
on the promotion of foods. We want to look at that and study it
so it is not something where we can either say carrot or stick
or somewhere on a defined point along that spectrum. Again, it
may matter what people say to us on different components of the
issues that contribute to the problem of obesity and to the possible
solution to it, actually where it ought to be positioned along
that spectrum. Broadly speaking, a lot of choices are being made
by individuals at the end of the day.
Q1321 Mr Bradley: You just mentioned
about the Food in Schools Programme as a pilot. Could you explain
a little more how that programme will be evaluated and how you
will come to conclusions about its benefits and how you will uses
that to expand similar programmes?
Miss Johnson: In terms of the
detail of how it is being evaluated I cannot go through that,
but there is an evaluation programme that is in place at the end
of the year to look at how that has been working. The pilot is
just to give a little more perspective. There are eight different
things running in each of eight regions affecting a number of
schools—secondary or primary or both—and what they
are doing is testing out things from making more drinking water
available (as I am sure you will know) to things like healthier
vending machines. I think one of the issues out of this is actually
how well those changes have contributed to what is going on about
food in the school, whether in fact you need to make a whole range
of changes in one place, for example, to really influence things,
as I think perhaps might seem sensible. We are discussing closely
with DfES both the work that is going on on that and other joint
cooperation with them on the whole question of food in schools,
its role, how schools can contribute and how those issues can
be taken forward.
Q1322 Mr Bradley: How are you actually
evaluating the effectiveness of those changes, whether it is water
or whether it is fruit? What are you actually doing on the ground
to say that this is making a difference?
Miss Johnson: On something like
the free school fruit, for example, we are evaluating that by
polling evidence which is actually showing that a quarter of the
children who are receiving free school fruit are actually having
more fruit at home and half of the families are recognising that
fruit and vegetables are more important in their diet than they
had previously thought. There is a significant impact there that
we are seeing on the free school fruit programme which I think
is receiving a lot of acclaim from both health practitioners and
the schools themselves. One of the other impacts that is going
on and is being seen in a number of schools is improved behaviour
as a result of better food or drink intake in schools. That is
something which I think is a real benefit and would indicate a
clear value not just, as it were, on the obesity side of things,
but in terms of the functioning of individuals and their ability
to learn.
Q1323 Mr Bradley: How are you measuring
better behaviour, for example?
Miss Johnson: The schools themselves
will anecdotally report some of this. There are some studies being
done, for example, of some of the bits of the programme that are
working that are being done through some academic institutions
looking at evaluating those results, but if you are asking me
about the detail of how those evaluations are carried out I would
be happy to write to the Committee with a bit more detail on the
evaluation process. It is there; we have an evaluation coming
up. I am just not an expert on the detail of how it will be done.
Q1324 Mr Bradley: Putting that in a wider
context, we have commissioned work on the health costs and the
wider economic costs of obesity as part of this process. Are you
gathering that some information together which presumably will
form part of the framework of the White Paper?
Miss Johnson: Sorry, which information?
Q1325 Mr Bradley: The wider economic
costs of obesity, not just the direct health costs. Are you gathering
together those wider economic costs to feed into the White Paper
that we will see in the summer?
Miss Johnson: Certainly I think
it is a key feature of a lot of the public health work that actually
if the public health work was done well—as Wanless demonstrated
very clearly—on a fully engaged scenario there is a huge
sum to be saved in terms of the cost to the Health Service and
the cost to the nation more widely. The individual sums are being
done wherever they can be, is the answer, because I think actually
it is a major contributing strand of thought that we actually
identify the costs that we are suffering as a result of being
more obese or any of the other issues in the main stream of public
health areas, and actually work out what the savings are that
could be achieved both in terms of money and in terms of quality
and length of life, and that we demonstrate those wherever possible.
I think Wanless has given a very clear steer on this, that actually
if we get fully engaged there is a lot more to be gained than
we currently have on a solid progress basis, which is where he
would mark us at the moment.
Q1326 Mr Burns: When was the free fruit
policy introduced and started to be operational in schools? What
proportion of school children actually receive it at the moment?
Miss Johnson: About half are currently
receiving it; something over a million. It started a couple of
years ago. I do not have the exact date but I can no doubt give
it to you in a second. By the end of this year all children of
infant school age in England will be receiving a free piece of
school fruit.
Q1327 Mr Burns: When you say year, do
you mean school year or calendar year?
Miss Johnson: Where it overlaps
with nursery classes I think they are starting, but basically
I think we are talking about school years broadly speaking. The
National School Fruit Scheme was introduced in 2001.
Q1328 John Austin: I certainly welcome
your statement that obesity is at the top of your priorities along
with smoking, but in relation to the impact on primary care your
Department has suggested that the targets within the National
Service Framework for coronary heart disease and diabetes in themselves
give sufficient priority to obesity. The evidence that we have
had from clinicians and managers suggests that that is not so
and there has been a strong call for a National Service Framework
for obesity as the only means for securing the funding and priority
that it deserves. One of our witnesses argued that primary care
services were working so hard to meet the other targets within
coronary heart disease and diabetes that they do not have either
the time or the resources to tackle obesity even though that would
bring down the rates of CHD and diabetes.
Miss Johnson: First of all, National
Service Framework for CHD means that you obviously need to focus
on obesity. You cannot tackle coronary heart disease without recognising
that obesity is a major contributory factor to it. Ditto with
diabetes, for example, where there is all the work going on with
diabetes. There is a forthcoming framework on children where again
clearly this is a major issue in terms of children. The question
of exactly how this work is taken forward obviously to some extent
supersedes the advent of the White Paper as well and clearly the
White Paper will hopefully draw more things together in an overarching
way to support the work on obesity than may previously have been
envisaged. However, what we are also saying is that the new GMS
contract provides a lot more opportunities and where it is being
done already very well under existing contract arrangements in
GP surgeries clearly a lot of advice is being given out, often
nurses are involved in giving that advice. There are 816 exercise
referral projects going on around the country with GP surgeries
referring people into exercise, whether it is at the local gym
or swimming pool or whatever. There are all sorts of different
programmes to help tackle the question of obesity. The new contract,
with its emphasis on health promotion work, does provide a renewed
opportunity at a general practice and primary care level for them
to focus more strongly even than they are at the moment on issues
like this one.
Q1329 John Austin: Obviously we would
welcome those improvements and I think perhaps we need to monitor
how the new contract will actually be delivering the kind of service
that we would all like to see. Nevertheless at the moment clinicians
and managers are saying to us that resources follow National Service
Frameworks and although tackling obesity brings down CHD and diabetes
the resources are not there for the preventive work on obesity
or, indeed, for treatment, and they are strongly calling for a
NSF. You also mentioned children. There is a National Service
Framework for children but that barely has any reference to obesity
in it.
Miss Johnson: The final Framework
on children has not been published yet.
Q1330 John Austin: Would you ensure that
there is a clear reference to obesity and prevention within the
children's NSF?
Miss Johnson: I am sure that is
an issue that will be covered as part of the National Service
Framework for children.
Q1331 John Austin: Do you not think that
a separate NSF for obesity is required?
Miss Johnson: No, is the answer
to that. I think it is well represented in the existing National
Service Frameworks, in fact. What we need to do as part of the
drive to better public health and to tackle the issue of obesity
is actually to encourage people to join up the issues that relevantly
need to be joined up and to make sure that people do not see things
simply in single pots, as it were. Of course we could have a National
Service Framework for obesity, but it would have to make substantial
reference to all the other National Service Frameworks and I think
you can see eventually it may not be a very productive way forward
for those who are trying to work and deliver things on the ground.
I think it is much more important that we encourage people to
see these things in the right context and, for example, we have
clear targets and are making huge improvements in bringing down
deaths from coronary heart disease and cancer—a 23% reduction
in deaths from coronary heart disease and 10% reduction in deaths
from cancer—so there is huge progress being made but the
Service is still very much focussed on those areas because it
has targets and it has frameworks and it has cancer plans. These
things are all extremely relevant to the question of tackling
obesity. We will not hit the targets in the medium to long term
unless we actually tackle the issue of obesity and some of the
health inequalities issues and smoking that we have to tackle
now. The Service needs to recognise that—as many of them
already do—and act on it fully. I think the best way of
doing that is by an integrated approach across where people understand
how everything fits together, which is what the White Paper will
help people to do.
Q1332 John Austin: I will be the first,
Minister, to congratulate the Government on the remarkable success
that the Government has had in relation to both coronary heart
disease and cancer, although obviously there is much more to be
done. If I could just focus on diabetes for a moment, we are a
little way behind the United States in terms of the growth of
obesity but we are going along the same road. We were told in
the United States that one third of the children born in 2002,
due to obesity, will be likely to develop Type 2 diabetes. We
are seeing for the first time in this country the diagnosis of
Type 2 diabetes in young people, a disease which was previously
reserved for perhaps people of my age rather than a younger age.
Has your Department made any estimate not only of the cost in
terms of human misery but the cost to the NHS and to your Department
if we do not stem the rising growth in Type 2 diabetes?
Miss Johnson: First of all, just
one or two of the facts and figures on it. It is as you say, broadly
speaking the vast majority of people who have diabetes actually
have Type 2 diabetes. Much of that can be related to obesity;
it is not exclusively related to obesity but it may well be. There
has been a very big increase in Type 2 diabetes. The estimate
at the moment is that diabetes could increase by as much as 58%
over the next 20 years which would be a huge hike and a huge health
bill as well. It is part of the work that Wanless has done in
looking at the gap between fully engaged and present scenarios
which indicates the size of that gap. It does not only look at
diabetes, as you are well aware, but it looks more widely. We
already have incentivisation at primary care level for GPs through
the outcomes and quality and outcomes framework to actually focus
much more on the management of patients with diabetes and obviously
that is something where we need to get a stronger focus, but where
the main objective must be to cut obesity and therefore to cut
the rates of diabetes in the future. As to figures—I think
you asked for an actual cost—I do not think I have a cost
to hand, but if we have one I would be very happy to try to get
it to you. Can I just say in terms of the free school fruit programme,
the actual pilot started in 2001.
Q1333 John Austin: Despite those alarming
figures and the fact that obesity is at the top of you Public
Health Agenda, can you still not be persuaded that there needs
to be a separate NSF for obesity?
Miss Johnson: How it is best to
bring these things together is something that we will look at
through the White Paper. However, I think—for the reasons
that I gave earlier on—superficially it is not a particularly
attractive option, to be honest, because we would simply be removing
from all the various settings where the question of obesity currently
appears and in a sense possibly remove it from the gaze of those
who are working on some of the key areas that would make a contribution.
On things like coronary heart disease and diabetes we may actually
be taking it away from those areas rather than actually creating—as
I know you would want to do through this—a stronger focus.
The question is what would get a stronger focus? I would argue
that a good understanding of how these things go together within
a clear framework where it is clear what the contributions of
different frameworks—the NSFs and the other standards that
we have produced—are to that, together with various other
incentivisations at health services level (like the ones that
we have through the new GMS contract and developing the existing
services that we have under the present arrangements) are the
sorts of things that will drive this agenda forward first in terms
of health service focus.
Q1334 John Austin: You mentioned equalities
in an earlier answer. We have very clear evidence that many minority
ethnic groups are at higher risk at much lower levels of overweightness
or lower BMIs. Does the Department have any targeted programmes
to get into those communities to tackle the issue which I think
is particularly a problem in some of the Asian communities?
Miss Johnson: That is certainly
correct. There are particular problems for particular sections
of the population who may be more at risk than others. I went
on a visit to Waltham Forest relatively recently where, indeed,
they are focussing on some of their ethnic minority populations
who are particularly at risk of diabetes. I think the answer,
as with a lot of the health inequalities in public health issues,
is to actually enable and make sure that at a fairly local level
the PCTs, the public health people and the services are focussed
on access and improving the health of their own particular populations
and the breakdown of those populations in terms of different groups,
and actually recognising the different issues that may give them
in the balance that they ought to be focussing on on things like
diabetes (it is true on a number of other areas too). Therefore
we can get significant improvements from that fairly localised
focus and that is indeed what is happening already in many parts
of the country.
Q1335 John Austin: If the Department
has any examples of effective community projects which are tackling
that, I think it would be extremely useful.
Miss Johnson: I will write to
you with some examples. In terms of the diabetes, the current
cost is 1.3 billion, but I think you were asking for the future
cost and we will see what figures we have in the Department on
that.
Q1336 Dr Naysmith: Minister, you have
already said this morning that the role of other government departments
is crucial in tackling obesity. I agree with that; who could not?
One important area must be a measure of coherence in working together
and the avoidance of giving mixed messages. The United Kingdom
Public Health Association and the Food Standards Agency have both
criticised support of schemes that link less healthy foods with
sport. Some have told us in evidence at this Committee that the
promotion of unhealthy foods is particularly obnoxious when linked
to an endorsement by high profile media personalities. The Sports
Minister, Richard Caborn, strongly endorsed the Cadbury GetActive
campaign and the Department for Education and Skills endorsed
a scheme where purchases of Walkers Crisps contribute towards
purchasing school equipment. We were told by your officials that
they did not know about these, they were not consulted about these
campaigns before they were endorsed by other departments. It would
not be unreasonable to imply that this does not demonstrate joined
up government very well.
Miss Johnson: I think it was not
a happy set of circumstances that led to that. It was before my
time in this post so I cannot comment on the detail of it, but
it was not a government programme and these programmes that you
are talking about were not government endorsed. I am sure that
is not something that is necessarily going to be repeated in the
future.
Q1337 Dr Naysmith: It is a fact that
the quote from Richard Caborn endorsing the campaign is still
available currently on the GetActive website. I do not know whether
it is possible to act retrospectively and do something about that.
Miss Johnson: I am sure you are
seeing the Department for Culture, Media and Sport; I think you
are seeing Tessa Jowell at some point before too much longer and
I am sure that is something you will want to raise.
Q1338 John Austin: In the interest of
joined up government would you have a message for the Minister
of Sport?
Miss Johnson: Not in this environment.
Q1339 Mr Burns: Are you saying you did
endorse the campaign?
Miss Johnson: It was not a government
endorsement, no.
| 
